The Asian Mental Health Collective (AMHC) Therapist Directory New Provider Application Form
Please check www.asianmhc.org/therapists-us/ for an existing profile before filling out this form. Duplicate submissions will not be considered.

(3/26/24 Update) If you are already on the directory and would like to be an LTF provider, please watch for an email from us! We are rolling out email-based verifications and will also have an FAQ page built specifically for those who are on the directory and are ready to become LTF providers. We thank you for your patience!

The information gathered here helps us build a resource for potential clients who might be seeking mental health providers in their area. If your application is accepted, you will be notified of further steps within 4-6 weeks at the email provided. Please be patient as we are always learning more about how this project can evolve and better fit the needs of providers and clients alike.

Approval of this application also serves as approval to be a Lotus Therapy Fund provider. Learn more about AMHC's Lotus Therapy Fund here.

If you have any questions, check out www.asianmhc.org/faq or reach out to it@asianmhc.org. If you have questions about becoming a Lotus Therapy Fund provider, reach out to therapy@asianmhc.org. 

Thank you so much for your interest in being included on our directory as your work and representation matter greatly.
Sign in to Google to save your progress. Learn more
Email *
Clinician Name (First and Last Name) *
Credentials (Professional Title) *
Please separate multiple credentials with a comma and one space
Ex. LPC, LMHCA, MHC-LP, LCSW, ASW, LMFT, etc.
Note: Student interns and life coaches will not be accepted
License Number(s) with Start and End Dates *
Please email licensure documentation to it@asianmhc.org for approval. Use subject line "AMHC Therapist Directory License Verification - Your Name" *
Supervisor License Number (If an associate licensee, license of supervisor is required. Otherwise put "N/A".) *
Professional Email (must not be a shared email address) *
Ex. john.dorris@asianmhc.org, NOT info@asianmhc.org.
Website URL
Phone Number
Country *
US State(s) of Licensure
Canadian Province(s) of Licensure
Self-Identified Ethnic Identity *
Note: Those with no Asian background at all will not be accepted
Required
Primary State/Province (Pick only 1) *
Use Full Title Text Format: "New York", "District of Columbia", or "British Columbia"
Primary City (Pick only 1) *
Use Full Title Text Format: "San Francisco", "Washington", "New York", or "Vancouver"
Primary Zipcode (Pick only 1) *
Values other than U.S. or Canada Zipcodes will not be accepted
Do you acknowledge that the information included in this form is subject to verification of publicly accessible information through state licensing boards in order to protect public safety. * *
Do you acknowledge that the Asian Mental Health Collective reserves the right to pause your participation in this directory if the information provided is not accurate, correct, or licensure status is unable to be verified? *
Do you acknowledge that your practice is not endorsed in any way by the Asian Mental Health Collective and all professional conduct and liability falls within the clinician's ethical and legal obligations of their respective licensing body? *
Do you agree to subscribe to the AMHC newsletter to receive updates about your AMHC Directory membership? *
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of Asian Mental Health Collective. Report Abuse
Google Forms